As the LA Times reports, an advisor to John McCain recently raised the ire of emergency docs by suggesting that the solution to the health care crisis is a change in the definition of uninsured. In his view, anyone with access to an ED has health care coverage.

"So I have a solution. And it will cost not one thin dime," John Goodman told the Dallas Morning News. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American-even illegal aliens-as uninsured."

The ACEP's response: "Emergency physicians can and do perform miracles every day, but taking on the full-time medical care for 46 million uninsured Americans is one miracle even we cannot perform. Access to care in the emergency department is no substitute for the comprehensive healthcare reform policy that should be at the heart of the platform of any presidential campaign."

Our question: Would that also mean that people are not homeless as long as they can hang around the library during the day?

A combination of news this week has served to make the pharma industry look particularly bad. First, the Washington Post reports on Genetech's refusal to explore whether Avastin works as well as super-expensive Lucentis in the treating the wet form of age-related macular degeneration.

Their efforts may all be in vain, however, says an article on Slate. The author points out that, for now at least, both Obama and McCain have taken a hard line on pharma, talking about their support for importation of low-cost generics from Canada. Let's hope the companies have been wisely investing that money they're saving by not giving away pens and dinners anymore.

In the course of reporting for an upcoming article on prediabetes (arriving online and in print in about a month), I interviewed endocrinologist Irl B. Hirsch, FACP, and he offered a few tidbits that didn't fit into the story but seemed worth sharing:

An increase in type 1 diabetes among adults. When asked what was the one thing he'd most like primary care docs to do to improve diabetes care, Dr. Hirsch suggested that they be alert to the fact that not all middle-aged new diabetics are type 2. "In my era we were all taught type 1 is kids, type 2 is adults. Often these people are misdiagnosed as type 2s. They are treated with pills, yet they need insulin," he said. Experts aren't sure why, but there's been a serious uptick in these cases in recent years, so if you see high glucose in a thin patient without a strong family history for example, keep type 1 in mind, Dr. Hirsch advised.

New ideas about screening methods. Citing a recent paper in the Journal of Clinical Endocrinology and Metabolism, Dr. Hirsch suggested that there may be a movement afoot to use A1cs as a diabetes screening tool. A1cs are reliable, don't require fasting and reflect longer-term glycemia, the consensus of experts who wrote the paper concluded. "What's interesting about that is that nobody recommends that we use A1c's for screening but about 50% of physicians already do," said Dr. Hirsch.

It's a classic image for the AARP set: The glass of OJ and the pile of pills next to one's plate at the breakfast table.

But this week, researchers presented a study that suggests orange, apple and grapefruit juice can reduce the absorption of some very important drugs, the New York Times and several hundred other news outlets reported.

Fexofenadine, ciprofloxacin, levofloxacin, itraconazole, atenolol, celiprolol, talinolol, cyclosporine, etoposide-- all are on the list of drugs affected by the three juices. And the study researchers from the University of Western Ontario suspect more will be added to the list, the Times article said.

Given that the jury is still out on how many drugs are affected by juice, what will/should physicians do in terms of educating patients about their prescriptions? Should they tell them to take all pills with water, to be on the safe side? Should they tell them why, or is that too much information to go into?

Should they tell certain patients to avoid drinking juice altogether (as has been done for years for patients who take drugs that interact with grapefruit juice), until more is known about how long the interaction effect lasts? What about eating an orange or an apple around the time one takes his or her pills-- should doctors address that, as well?

In other words, what should doctors do with information like this, while they wait for more clarifying research to emerge? It seems like a tough spot to be in.

Medicare released its first round of bonus payments to physicians who reported quality care data. But physicians say the actual payouts are relatively small and might not be worth the record-keeping, and report problems learning how well they performed.

The Centers for Medicare and Medicaid Services (CMS) introduced the Physicians Quality Reporting Initiative in July 2007. The program awards a bonus payment of 1.5% of allowed charges for Medicare patients to physicians who submitted quality measure codes. Since then, between 10 and 15 percent of internists reported at least one quality measure code, and slightly more than half earned a bonus. ACP will report more specific outcomes to members in the near future.

Internist William E. Fox, FACP, an internist in Charlottesville, Va., writes that his practice received a bonus payment below the average amount that Medicare had reported. He said that's probably because his practice is four years old, with a smaller patient panel and fewer Medicare patients.

But established internist W. James Stackhouse, MACP, of Goldsboro, N.C., received his bonus payment and questioned if it's worth continuing participating, even using simplified alternative reporting shortcuts that were released this year. He writes, "It took a lot of paperwork and screwed up billing because we had to charge 1 cent per code so that the Medicare carrier's computer would pick up the charges, and then had to manually write off that charge afterward."

His back-of-the-envelope math estimates a physician could reasonably recoup $6,000 in bonus payments, "which represents an extra 99213 visit only about 120 times in year, or about one every other day of office hours." He added that's little motivatation for the extra record-keeping.

Also, physicians who participated in the 2007 PQRI are supposed to be able to find out how they performed on a secure Web site. However, Dr. Fox has been so far unable to access his reports, a complaint voiced by users during a public forum CMS conducted, according to ACP's Regulatory and Insurer Affairs staff. Since doctors who have a bad first experience may not continue, ACP is reporting its members' frustrations back to Medicare.

Dr. Fox asked, "I wonder what results others have had?" ACP is working with the American Medical Association to survey internists about their experiences, as detailed in a report here.

In 2007, 56% of U.S. adults sought info about a health concern from a source other than their doctor, according to a new study from the Center for Studying Health System Change. That's up from 38% in 2001. This, of course, corresponds with a rise in the use of the Internet as a source of info (from 16% in 2001 to 32% in 2007).

The more education a person has, the more likely she is to seek information on her own, the study found. Women are more likely than men, younger folks are more likely than older, whites and African Americans are more likely than Hispanics, and people with higher incomes are more likely than those with the lowest incomes. None of which is too terribly surprising.

The majority of these folks reported that getting information on their own was a positive thing, because it helped them to understand their own health concerns. I'd really be interested to hear how doctors view this trend. Does it add to the workload and stretch the 15-minute visit, if a patient comes in with a laundry list of ailments printed from the Internet? Has a patient ever helped a doctor focus in on a diagnosis, or brought symptoms to light that might have gone undetected, thanks to the patient's research?

Back in May, we wrote about CMS' new and improved Hospital Compare Web site , which compares hospitals using data on dozens of quality, outcome and patient satisfaction measures.

Now CMS has added a mortality measure for pneumonia as well as measures for hospital care of children. The latter is really different, as previous information only focused on data derived from adult hospitalizations.

The measure on 30-day mortality from pneumonia joins existing 30-day mortality measures for heart failure and heart attack. CMS started reporting those heart measures last summer, and says in a press release that it has seen those rates improve in the meantime. The heart attack mortality rate dropped to 16.1% in 2008 from 16.3% in 2007, for example.

The site now includes a total of 26 process-of-care measures, three outcome measures, two children's asthma care measures, and 10 patient experience measures.

People who take care of a spouse with dementia are more likely to be depressed than those who don't, according to a recent study in International Psychogeriatrics.

Your brain processes a person's face more efficiently if that person is looking straight at you than if his or her gaze is averted, a study out of Finland finds.

There are more house fire deaths in states where a higher percentage of people smoke at home, according to a CDC study in Injury Prevention.

And finally, that whole "beer goggles" thing, where people look better when you've had a bit to drink? It is officially for real, this study of English college students found. I bet they had no trouble recruiting volunteers for that study...

I've been wondering about all this new research on the mortality benefits of Vitamin D for a while now. (Do Americans really get that little sunshine? Could there be some confounding factor, such as that sedentary and sickly people don't spend time outside?) So I was excited to see that the NIH is a little suspicious too. They recently convened a conference to investigate the existing evidence on Vitamin D. I haven't had time to fully review the resulting 20 research papers, but I'm interested in the practice perspective on this issue. Have any patients asked you about Vitamin D? Are you testing their levels? And are you recommending that patients increase their intake--by sun exposure, diet or supplements?

Warfarin is a very challenging drug to prescribe and manage. Not only is the therapeutic window narrow, but achieving the correct dose and maintaining a stable international normalized ratio (INR) for patients can be problematic. Any reasonably cost- and time-effective improvement in warfarin management would be welcomed by most clinicians.

Over the last several years new genetic tests for variants in the CYP2C9 and VKORC1 genes have been developed that predict a substantial component of warfarin metabolism. Many scientists and academic health care providers feel that prospective use of these tests may save lives and health care resources. To date, several small studies comparing the use of genetic testing to standard of care have produced mixed results. There may be evidence for reduced use of blood draws for INRs and office visits, but no large trial has demonstrated a mortality benefit. The FDA has altered warfarin's labeling to reflect this new information.

A number of companies and health care systems already have geared up to offer warfarin pharmacogenetic tests with a rapid turn-around time. The National Heart, Lung and Blood Institute of the National Institutes of Health started a major trial of warfarin pharmacogenetic testing through the University of Pennsylvania, which should greatly enhance our understanding of the clinical utility of such tests.

Interestingly, the Centers for Medicare and Medicaid Services opened a National Coverage Analysis (NCA) of the topic. The public comment for this NCA runs until Sept. 3. For some in the personalized medicine community, this NCA is viewed as a critical test case of personalized medicine predicated on genomic information. Perhaps this overstates the situation. It probably is best viewed as an opportunity for a much-needed dialogue between supporters of personalized medicine and evidence-based medicine.

Will the nation's largest health care payer accept the current evidence supporting the use of warfarin pharmacogenetic testing in routine care? A recent review using the Rapid ACCE format by McClain et al. raised serious concerns regarding gaps in the current evidence base. However, this is a rapidly moving field and more data are now available.

In a time of rapid advances in genetics and genomics and spiraling health care costs, any significant "evidentiary gap" will be increasingly problematic for promising and potentially very significant improvements in standard of care. Substantial resources should be directed at re-tooling our research and health care delivery systems to rapidly and responsibly generate the types of effectiveness data needed to separate the wheat from the chaff in genomics, and more broadly, all emerging health care technologies.

W. Gregory Feero, MD, PhD, a family physician with a doctorate in human genetics, is senior adviser for genomic medicine in the Office of the Director at the NIH's National Human Genome Research Institute. His column runs every issue in ACP Internist

Today's New York Times features several couples who are considering marriage or divorce for health insurance reasons. The story cites a Kaiser poll in which 7% of respondents said someone in their household had married for insurance in the past year. That statistic seems shockingly high, and the polltakers caution that it shouldn't be taken literally, but I personally know a young couple who cancelled their wedding so the groom could continue receiving care for his terminal cancer under his parents' insurance (a twist the NYT didn't cover). What kinds of extreme measures have you seen patients take to get or keep health insurance? Is this a trend that will affect the practice of medicine, or marriage?

New onset rates for active-duty personnel were 6.0%, 26.6%, and 4.8 percent, respectively.

It's quite possible these soldiers are using alcohol to cope with PTSD or other mental illness, the authors said, as there is a well-established link between the two. We'll discuss what internists can do to spot and treat soldiers with PTSD in the upcoming September cover story of ACP Internist.

Till then, do any of our readers want to share their stories of treating vets from the current war? Have you had many vets as patients? What have been the challenges, and how have you dealt with them?

Having excess fat surrounding your heart is more likely to cause heart attacks than excess fat around your waist, a study in Obesity finds. Also, accidentally hitting your thumb while hammering is more likely to bruise your thumb than your shoulder. (That comes from a "study" I conducted in my living room the other week.)

Also, in obesity news: People who live in more walkable neighborhoods are less likely to be overweight or obese than people who live in neighborhoods where they have to drive everywhere, according to a study in the September American Journal of Preventive Medicine. Also, people who live down the street from a great pizza joint are more likely to spontaneously bring home a pie for dinner than those who don't. (Again, based on personal research.)

And, a series of headlines from the Washington Post that require (or deserve?) no explanation:

The New England Journal has a helpful article on preventing malaria in patients taking short jaunts to foreign countries. Might be worth a look, as safaris in Kenya, Tanzania, etc, become more popular (as does exotic travel in general, though this may change given the economy.)

First step: Check here to see what the malaria risk is in the patient's destination country.

IDSA guidelines say that, for countries where there isn't resistance to the drug, chloroquine should be your first stop. Sadly, there's a lot of chloroquine resistance, esp. to falciparum malaria-- the most deadly kind. Choloroquine still works in Mexico, the Carribean, East Asia and parts of C. America and the Middle East.

For other areas, you should prescribe atovaquone-proguanil, mefloquine, or doxycycline. Your choice will depend on several things, like the patient's medical history, age and economic situation; this table in the NEJM article compares them and can help you suss out the best option.

And, of course, don't forget to tell your patients bound for malarial areas to wear insect repellent with DEET, long sleeves/pants and footwear, and use nets, screens or AC and closed windows when sleeping.

Three recent items point out to harried internists what patients really want when they see their doctor--communication.

Along comes the American Board of Medical Specialties, who released a survey that bedside manner outranked certification as a reason why patients like their doctor. Good communication was important to 95% of respondents, as opposed to certification (91%). Not to state the obvious, but it's important when the body that certifies physicians says their raison d'etre is second place to patient communication. Actually, they explain how one is related to the other here.

Next, from the trenches of good primary care, comes Dr. Rob, who has posted six commonsense rules for working with patients.

Finally, the cover story to July's ACP Hospitalist examines the difficulty of balancing being right and being polite. Says one doctor (and he is not alone in his opinion) "You're training me to be an expert and now you're going to ask me to be nice about it at the same time? As physicians, we're not trained to deal with a lot of this stuff."

How can internists balance everything they have to do and then relate it to the patient in a 10-minute visit?

The XVI International Conference on AIDS is being held in Mexico City this week and some studies presented there highlighted new avenues for cost-effectively combatting HIV:

In two African studies (reported in the Washington Post), researchers compared outcomes for HIV patients who had their care led by specially-trained nurses with a group receiving standard care from doctors. The clinical results were the same, but the nurses' patients were more confident in managing their own care and took their meds more regularly. The results aren't likely to put any of you out of a job, but may be useful in areas with severe physician shortages.

Of course, reducing the quantity of new HIV infections would give both doctors and nurses less to do. A new mathematical model from Canadian researchers proposes to do just that, by giving poor patients more access to HAART. The study calculated that if British Columbian health authorities could increase HAART coverage from 50% to 90%, the rate of new infections would drop by half. A convincing argument for good prescription coverage.

Here is something to keep in mind if you encounter foreign-born patients from Sub-Saharan Africa and SE Asia in your U.S. practice or hospital.

A new JAMA study found folks from these areas-- and now living in the US-- were the most likely foreign-born patients to have latent TB. Vietnamese and Filipinos had some of the highest rates, as did Peruvians.

Of course, U.S.-born patients can get TB too; in 2006, they accounted for 43% of cases vs. 57% by foreign-borns.

It seems that extensively drug-resistant tuberculosis (XDR-TB) can be cured in HIV-negative patients via outpatient treatment, even in countries with limited resources.

More than 60% of Peruvian patients with XDR-TB in the study were cured after getting personalized, daily treatment at home or in community settings. That's a better cure rate than at most US and European hospitals.

The success of the setting is important, as XDR-TB patients are forcibly quarantined in unsavory TB hospitals in some countries, the authors noted. Perhaps the study will help put an end to that practice.

First, from Iran, news reports that should make U.S. internists glad that their biggest problems are low reimbursement and noncompliant patients. Two Iranian AIDS researchers, who are also brothers, were arrested in June and have not been heard from since. Physicians for Human Rights is asking people, especially health professionals, to sign a petition for their release.

Then, in a controversy closer to home, NYC med schools and hospitals are battling over whether the hospitals can make a profitable deal to provide a large number of clerkships to students of a Caribbean med school. The med schools argue that the deal will squeeze their students out of clerkships and force them to raise tuition higher than the U.S. average, while the hospitals say they need the money. However, the argument, and the New York Times article, devolves into a nasty debate about the value of foreign medical education, with one hospital representative comparing NYC med schools to children crying, "Daddy, I can't have my free candy anymore." Whoa.

Seems like everyone is getting on the conflict-of-interest bandwagon when it comes to drug companies.

New FDA guidelines prohibit the experts who advise during committee meetings to participate if they, their spouse or minor child have more than $50K financial interest in the companies that will be affected by their actions at the meeting.

Below $50K, the expert may get a waiver by the FDA to participate, but only if his or her input is deemed essential. The number of waivers given will be limited, and FDA will post on its Web site, in advance of the meeting, the reasons for each waiver.

Other changes:

-Advisory committee members must now vote all at once, insted of one-at-a-time. the aim is to avoid "momentum" that could sway people to vote in line with those who preceded them.

-Votes will be immediately announced at the meeting.

-Committee member votes will be posted on the FDA Web site.

-FDA will post the background materials it gives to committee members on its Web site at least 48 hours before the meeting starts.

What do you think of these guidelines? Is $50K a reasonable cutoff? How difficult is it to find experts who have little or no financial interest-- as from consulting or speaking fees-- in these companies? Do the voting and waiver rules go far enough to ensure transparency?

In case you hadn't noticed, the Archives of General Pyschiatry tells us this week that today's psychiatrists are focusing on drugs instead of therapy. From the press release:

Various forms of psychotherapy, either alone or in combination with medications, are recommended for the treatment of major depression, post-traumatic stress disorder, bipolar disorder and other psychiatric illnesses. "Yet, despite the traditional prominence of psychotherapy in psychiatric practice and training, there are indications of a recent decline in the provision of psychotherapy by U.S. psychiatrists—a trend attributed to reimbursement policies favoring brief medication management visits rather than psychotherapy and the introduction of newer psychotropic medications with fewer adverse effects," the authors write.

Also, girls who develop earlier than their peers and have uninvolved parents are likely to get into trouble, the Archives of Pediatric and Adolescent Medicine reports. "By discussing difficult peer situations (e.g., provocation, peer pressure) and ways of dealing with them, parents may help their daughters develop a repertoire of adaptive responses that will minimize the need for inappropriate (i.e., aggressive) behavior," the authors write. "In addition, knowing how their daughters spend free time may help parents identify and prevent negative peer and other influences." Who knew?

You can also go here to order a free print copy of a booklet or fact sheet, or call 1-800-891-5390 to order copies. Packets of 25 copies of booklets and fact sheets cost $10 and $5, respectively, to cover shipping and handling.

On the heels of a study that found pre-pregnancy diabetes increases the risk for birth defects, the NIDDK is giving away a patient guide: "For Women with Diabetes: Your Guide to Pregnancy".

It's a 44-page booklet with info about checking and controlling blood glucose, maintaining a healthy diet, staying active and taking tests and diabetes medications during pregnancy. It also includes logs for recording daily blood glucose and ketone levels, food intake and physical activity.

The new booklet is available online in English, with a Spanish version coming soon.

You can also order a print copy via this site or by calling 1-800-860-8747.

New research in mice has developed a drug that gets sedentary animals into shape. "Sedentary mice that took the drug for four weeks burned more calories and had less fat than untreated mice. And when tested on a treadmill, they could run about 44 percent farther and 23 percent longer than untreated mice," reported the AP story. The scientists expect that the discovery could eventually lead to new treatments for obesity and diabetes (as well as new performance enhancers to ban), but they caution that no new invention is likely to beat the benefits of hard-earned sweat.

Those dedicated mice brought another discovery to today's news, namely that a compound in tetrahydrocannabinol (found in the cannibis plant) may suppress the development of colorectal cancer. Conveniently, it's the same receptor that causes cannibis to relieve pain and nausea, elevate mood and stimulate appetite--an all-in-one benefit for cancer patients.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.
ACP Internist
provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.